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Get Printable Reporting Form - Hennepin County

65 - Health Services Building 525 Portland Avenue South Minneapolis, MN 55415-1569 SUSPECTED CHILD MALTREATMENT REPORT Alleged Offender Name of Alleged Offender Birthdate or Age Gender Male Address State City ZIP Code MN Home Phone Cell Phone Work Phone Offender Relationship to Family or Child Family Mother Name of Mother Birthdate or Age Address State City ZIP Code MN Home Phone Work Phone Cell Phone Father Name of Father Birthdate or Age Name of child Address State C.

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